Emergency Form | Sunrise CFC

Emergency and Permission Form

Please fill out a separate emergency form for each child.

* indicates required field

Child's First Name

Child's Last Name

Age

Birthday

Gender

Parent/Guardian 1 First Name

Parent/Guardian 1 Last Name

Parent/Guardian 1 Email

Parent/Guardian Phone 1

Parent/Guardian Phone 2

Parent/Guardian 1 Home Phone

Parent/Guardian 2 First Name

Parent/Guardian 2 Last Name

Parent/Guardian 2 Email

Parent/Guardian 2 Cell Phone

Parent/Guardian 2 Work Phone

Parent/Guardian 2 Home Phone

Street Address

City

State

Zip

Medical and Emergency Information

General Condition of Health

Comments

Date of Last Physical

Physical Limitations

Allergies to Food or Other Substances

Current Medications

If your child needs to take medication while at the farm, please bring it in the original bottle with specific directions for administering.

Primary Physician

Phone

Hospital Preference

In case of an emergency we will always try to contact parents/guardians first. Should we be unable to reach you, please give us the names and phone numbers of two other people we should be able to reach during the hours your child is at the farm (8:00am-6:00pm):

Emergency Contact 1 Full Name

Phone Number

Relationship (e.g. Aunt, Neighbor, etc.)

Emergency Contact 2 Full Name

Phone Number

Relationship (e.g. Aunt, Neighbor, etc.)

Please list the first and last names and phone numbers of everyone who has permission to pick up your camper, including yourself. Anyone picking up for the first time should be prepared to show a photo ID.

Approved for Pick Up

I certify that the above information is correct

Electronic Signature

Date

Sunrise Community Farm Center

Emergency and Permission Form

Medical and Emergency Information

Sunrise Community
Farm Center